INTRODUCTION

In a 2022–2023 national survey, 30% of Australian adolescents aged 12–17 years reported ever having used electronic cigarettes (e-cigarettes)¹, despite national laws and policy that prohibit the sale or supply of e-cigarettes to those aged <18 years². Many products are specifically designed and marketed towards adolescents³. Numerous e-cigarette health impacts have been identified including: addiction; poisonings both intentional and accidental; nicotine toxicity from inhalation; burns and injuries; lung injury; and increased smoking uptake in non-smokers^4-6. The adolescent brain undergoes extensive neural development making adolescents particularly vulnerable to both the short- and long-term health impacts of nicotine⁷. Given the harms of e-cigarettes and the high prevalence of use, it is crucial to maximize efforts that prevent e-cigarette use among adolescents.

Sport participation and exercise are often postulated as potential protective factors against some risk behaviors, such as smoking, as they support physical health and promote overall wellbeing, encourage self-discipline and foster success-oriented mindsets, and behaviors that could compromise these benefits should be avoided⁸. In Australia in 2019, 89% of adolescents aged 15–17 years participated at least once a week in physical activity for sport, exercise or physical recreation. Fitness/gym, athletics and football/soccer were the most popular, and participation was motivated by fun/enjoyment in 71% and by health reasons in 64%⁹. Several studies have suggested that active adolescents are less likely to be regular smokers while others report no association or that physical activity or sport participation is associated with greater odds of tobacco smoking with variation by the frequency and intensity of physical activity, the competitive level and type of sport, and age and sex¹⁰. For example, one study found that compared to adolescents participating in sprint and resistance sports, those in team sports were three times more likely to be current smokers and another found that adolescents had four times the odds of smoking progressions (initiation or increased use) for every 30 min/week spent engaging in activities such as sport fighting, competitive wrestling and cycling, while those participating in racquet sports and swimming had around half the odds of smoking progression compared to non-participants^11-13. Internationally, few studies have examined the relationship between adolescent e-cigarette use and physical activity, and we were not able to locate any that had done so qualitatively.

One cohort study found current e-cigarette users were more likely than non-users to participate in any type of physical activity¹⁴, one found that team sport, but not individual sport participation, was associated with greater odds of e-cigarette experimentation but among boys only¹⁵, and another cohort study found adolescents who met the physical activity guidelines were more likely than other adolescents to initiate e-cigarette use¹⁶. From cross-sectional data, compared to non-users, e-cigarette users were more likely to engage in various types of physical activities or sport, particularly for males¹⁷ and e-cigarette users were less likely to obtain ≥60 min/day moderate-vigorous physical activity but were no different for other physical activities¹⁸. Also five cross-sectional studies explored how sports participation related to e-cigarette use, finding that: competitive sport, sport outside of school and 60 min/day moderate-vigorous physical activity were positively associated with e-cigarette use¹⁹; any team sport participation was associated with use²⁰; participation was associated with lower odds of use²¹; there was no difference in use by sport participation^22,23.

The quantitative evidence – which is largely cross-sectional – on the interaction between sport, physical activity and e-cigarettes among adolescents is limited with inferences on causality and directionally unavailable and there is an absence of data describing potential mechanisms driving the relationship. It is unclear whether e-cigarette use influences physical activity participation with implications for adolescent health more broadly or supports sport participation as a protective factor against e-cigarette use, and, in fact, it may suggest the opposite. Therefore, there is a need to explore this relationship in more depth to better understand its complexity and nuance. To our knowledge, this is the first study aiming to qualitatively explore the relationship of e-cigarette use to sport participation and physical activity, including the impacts of sport on e-cigarette use and vice versa, and is based on data from adolescents aged 14–17 years.

METHODS

This study used online single or paired semi-structured interviews from the Generation Vape research project – a four-year (2021–2025) multi-wave study with six-monthly quantitative and yearly qualitative data collection – designed to explore e-cigarette awareness, perceptions, attitudes, and knowledge among Australian adolescents aged 14–17 years²⁴. Ethics approval for the project was granted by the University of Sydney Human Research Ethics Committee. A professional research recruitment agency used online panels for recruitment. Equal quotas of participants by e-cigarette use (ever and never users), sex (males and females), and school type (private and government) and 75% metropolitan participants (to reflect the geographical distribution of the general population) were obtained to enable the collection of a broad spectrum of experiences from participants with a range of different characteristics²⁴. Respondents were screened following initial contact and were eligible for inclusion if they lived in Australia, had heard of e-cigarettes and reported that their age was 14–17 years. After receiving a Participant Information Statement, consent was obtained from both parents and participants.

Interviews were conducted during February–May 2023 (wave four) and consisted of 78 interviews (60 single and 18 paired) including 96 participants. They were approximately 30 minutes in length and held via Zoom by one of two interviewers using a piloted discussion guide. Interviews were audio recorded, transcribed verbatim and de-identified. Participants were not directly asked about sport and e-cigarettes and there were no specific questions relating to this in the interview guide. All discussion was raised unprompted by the participants with possible probing questions by the interviewer for follow-up and greater understanding. Therefore, the analytical sample is derived from a subset of the 96 participants who, by their own account, volunteered information on this topic.

The reflexive thematic analysis process, as outlined in Braun and Clarke²⁵, was adopted for data synthesis as it facilitates the development of patterns of meaning (themes) while acknowledging the active role of the researcher in analysis. The process involved several – not necessarily sequential – phases²⁵. Familiarization of the dataset occurred via repeated listening of audio recordings and reading of transcripts. Manual inductive coding was undertaken and codes, associated text excerpts and participant characteristics were copied into an excel spreadsheet. Codes were generally semantic with latent or higher level interpretations recorded in an accompanying note (Supplementary file Table 1). Coding was completed by one reviewer (AY), then revised and discussed with all authors, from which initial themes were generated²⁵. Themes were reviewed and refined – with the input from all authors – and data were arranged into a logical and meaningful narrative guided by the research aims.

RESULTS

The relationship between sports, physical activity and e-cigarettes was important to adolescents, as was demonstrated by the wealth of discussion which was entirely unprompted and initiated by participants. Of the 96 participants in the sample, 52 (54%) discussed the subject in some manner [52% females; 65% 16–17 years; 56% government schools; 19% never users; 21% former users; and 60% ever users (current and occasional)].

DISCUSSION

This study demonstrates the complex and dynamic relationship between sport, physical activity and e-cigarette use, and how this is perceived among Australian adolescents. Discussion of the relationship between sport and e-cigarettes was unprompted, but was repeatedly raised by participants signifying the salience of the issue for adolescents. Sport participation and performance was viewed of great importance with its preservation driving abstinence (non-use) and cessation. For one participant, the benefits from sport were considered so impactful that they negated any potential harms of e-cigarettes. For most adolescents, sport, fitness and physical activity were perceived to be negatively impacted by their e-cigarette use. Shortness of breath was the most common impact reported, which was even experienced during low intensity day-to-day activities such as walking or climbing stairs, although some did not report any impacts at all.

The current evidence regarding the relationship between sport and e-cigarette use is scarce, varied and quantitative. It broadly suggests that among adolescents, e-cigarette use is associated with greater physical activity levels and sports participation. Evidence from a Canadian prospective cohort study found that, compared to non-users, there was a greater likelihood of participating in moderate-vigorous physical activity, strengthening exercises and sport participation among current e-cigarette users¹⁴ with the findings supported by another Canadian study (cross sectional)¹⁷. However, cross-sectional data from the US found that there was no difference in the odds of vigorous physical activity or muscle strengthening physical activity between e-cigarette users and non-users, and that e-cigarette users were less likely to obtain ≥60 min/day moderate-vigorous physical activity¹⁸.

Evidence also suggests that sports participation is associated with greater e-cigarette initiation¹⁶, but may vary by gender, sport type and competitive level^15,19,20. For example, cross-sectional data form the US found that team sport, but not individual sport participation, was associated with greater odds of e-cigarette experimentation among boys but not girls¹⁵, and that any team sport participation was associated with e-cigarette use, and was greater for intermittent users than frequent users²⁰. Among Canadian adolescents, competitive sport, sport outside of school and 60 min/day moderate-vigorous physical activity were positively associated with e-cigarette use while competitive sport was negatively associated¹⁹. However, other cross sectional evidence found sports participation was associated with lower odds of e-cigarette use among Irish adolscents²¹; that there was no association between e-cigarette use and intramural sport participation in Canadian adolscensts²², and by competitive sport participation (frequency or type) among US adolescents²³. While this evidence would appear counter to our findings, most data are cross-sectional and describe only the relationship at a single point in time; however, it is unlikely that this relationship remains static over time. Instead, the influence of sport on e-cigarette use or vice versa, is dynamic and as evidenced by our study, it changes depending on efforts to improve sporting performance, and personal experiences of adverse e-cigarette health effects or decline in sporting participation and fitness. Given the importance of the sport–e-cigarette interaction for adolescents and the fluidity of the relationship, a valuable opportunity presents for leveraging this interaction to promote e-cigarette prevention campaigns to support overall adolescent wellbeing.

Although there is conclusive evidence that use of e-cigarettes can lead to e-cigarette or vaping associated lung injury (EVALI), there is insufficient evidence regarding other important clinical respiratory outcomes (such as chronic obstructive pulmonary disease), and subclinical outcomes including lung function and lung capacity⁶. One small experimental study was identified that considered cardiorespiratory impacts of e-cigarettes in young adults, which found significantly reduced cardiorespiratory fitness among e-cigarette users compared to non-users²⁶. Although certain kinds of evidence may be lacking, this study shows that reductions in lung function – perceived or otherwise – and shortness of breath are meaningful and important to adolescents. These impacts are considered so detrimental, particularly to their sporting aspirations or overall fitness, that they are reported as contributing to patterns of use including abstinence and cessation. While these symptoms are indicators of respiratory function, potentially short-lasting and may not be indicative of clinical disease, given their salience for adolescents and the very real negative impacts experienced, it is important that they are not overlooked in health messaging. An Australian anti-vaping campaign ‘Every vape is a hit to your health’ targeting participants aged 14–24 years has recognized the relevance of this symptom and made one of their key messages about breathlessness²⁷. Made apparent through sport and physical activity, Australian adolescents report experiencing the health effects of e-cigarettes and these narratives, told in their own voice, provide compelling and believable dialogue that is likely to resonate among other adolescents. This juncture between sport, health and e-cigarettes likely provides another entry point for health promotion and e-cigarette prevention activities.

Aside from the physical benefits derived from physical activity and sport, there are numerous other benefits including supporting social, academic, and emotional wellbeing^28,29. Sport participation and recreational or leisure time physical activity can support mental health, foster community connections, and promote social interactions and relationships^29,30. There is also evidence suggesting that children and adolescents that participate in sport are more likely to be active in adulthood than those that do not²⁹. If the effects of e-cigarettes experienced by adolescents, such as shortness of breath, reduce their ability to engage in sport or recreational physical activity, adolescents miss out on the complete and extensive range of benefits it provides.

The public health implications of the relationship between sport and e-cigarette promotion must also be recognized. Elite athletes are often positioned as positive role models for adolescents, promoting not only athletic prowess but also healthy lifestyles. It can be particularly damaging if these public personas either intentionally or unintentionally demonstrate favorable attitudes towards e-cigarettes that normalize their use or minimize their harms. For example, an Australian rugby player, subsequently dismissed over this incident, filmed and uploaded to social media a video of themselves vaping during half-time of a national league game³¹. In 2022, an e-cigarette retailer in the UK – with links to Phillip Morris International – recruited a former football star as campaign ambassador promoting vaping as the answer for achieving smoke-free societies³². Tobacco companies have a long history of sponsoring sporting players, teams and events as they aid in associating their brand with healthy lifestyles, reaching younger audiences and often provide an avenue to evade advertising restrictions^33,34. Furthermore, the broadcasting of sporting events and the creation of programs centered on specific sports, such as Netflix’s ‘Drive to Survive’, the tobacco industry benefits from extensive brand exposure, with approximately 33% of the show ‘Drive to Survive’ displaying tobacco branding – predominantly e-cigarette and nicotine pouch products – equating to around 35 minutes per viewer³⁵. Unsurprisingly, the e-cigarette industry has also adopted this tactic sponsoring football teams³², and sports grounds (Cigg-e Stadium in Wales, 2013)³⁶. In recognition of the invaluable reach and access sport sponsorship provides to industry, policymakers should apply comprehensive bans on e-cigarette advertising and promotion, as a key component of effective tobacco control.

CONCLUSIONS

Sport participation and performance were considered key drivers of adolescent e-cigarette use behaviors including abstinence, cessation and ‘responsible use’. Most current and former users reported experiencing health harms attributed to e-cigarettes – predominantly shortness of breath – during day-to-day activities such as walking or climbing the stairs and during sporting activities. E-cigarette use in adolescents may jeopardize the physical, mental and social benefits of engaging in sport and recreational physical activity. There is a need for greater regulation of e-cigarette industry sponsorship of sport to reduce adolescent exposure to e-cigarette marketing and promotion. Anti-vaping campaigns aimed at adolescents that stress the impacts on physical fitness are also a potential effective intervention.